Provider Demographics
NPI:1609858240
Name:DOUGLAS, CHAD JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:JAMES
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 E MARKET ST STE 5
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2259
Mailing Address - Country:US
Mailing Address - Phone:330-394-2020
Mailing Address - Fax:330-395-7194
Practice Address - Street 1:5000 E MARKET ST STE 5
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2259
Practice Address - Country:US
Practice Address - Phone:330-394-2020
Practice Address - Fax:330-395-7194
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5523T2435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2982116Medicaid
OHDO4163442Medicare PIN